EBV Seropositivity Research Articles

2168. Viral DNAemia and Herpesvirus Seropositivity are Associated with Mortality in Pediatric Patients with Severe Sepsis

Abstract Background Sepsis is a leading cause of pediatric mortality. Little attention has been paid to latent and reactivated viral infection in critically ill children with sepsis. We report a large multi-center study of viral DNAemia and herpesvirus seropositivity in pediatric patients with severe sepsis. Methods We enrolled 401 pediatric patients from 9 Pediatric Intensive Care Units (PICUs). Patient samples were tested via qPCR for EBV, CMV, HSV, adenovirus, HHV6, BK and parvovirus B19 DNA. CMV, EBV, HSV and HHV6 IgG were also measured to classify patients as having no infection (IgG-negative without DNAemia), acute infection (IgG-negative with DNAemia), reactivated infection (IgG-positive with DNAemia), or latent infection without reactivation (IgG-positive without DNAemia). Results 55% of enrolled patients were male, 39% previously healthy, and 27% immunocompromised. 56% had documented infection(s) on enrollment (63% bacterial, 50% viral, and 2% fungal). 11% died in the PICU. Viral DNAemia was detected in 61% of immunocompromised patients and 46% of non-immunocompromised patients. DNAemia with 2 or more viruses on study, detected in 21% of patients, was independently associated with increased mortality in both immunocompromised (OR 5.5 [1.6, 22.6] p=0.023) and non-immunocompromised patients (OR 3.9 [1.4, 11.5] p=0.015). Viral detection was due to reactivated infection in 91% of patients with EBV DNAemia, 63% with CMV, and 100% with HSV and HHV-6, making acute infection rare. Viral seropositivity (HSV 33%, CMV 42%, EBV 61%, HHV6 98%) and latent infection (HSV 30%, CMV 35%, EBV 45%, HHV6 75%) were both common. Adjusted mortality was higher in patients seropositive for EBV (OR 9.1 [2.8, 172.8], p=0.002) compared to those seronegative for EBV. For HHV-6, mortality was higher in patients with viral reactivation compared to latent infection (18% vs. 7%, p=0.024). Mortality in patients with no detected viral infection (IgG-negative without DNAemia) was low (≤ 5% for each virus). Pediatric Sepsis Mortality and Viral DNAemia ICU mortality was significantly associated with the number of viruses detected during ICU stay in both non-immunocompromised patients (light grey bars) and immunocompromised patients (dark grey bars). In patients with 0 viruses detected, morality was less than 10% in both groups. If 1 virus was detected, mortality was 6% in non-immunocompromised patients and 14% in immunocompromised patients. In the 47 non-immunocompromised patients in which 2 or more viruses were detected, mortality was almost 25% and in the 31 immunocompromised patients mortality neared 40%. Among all patients, additional viral detection of 3, 4 or more viruses by PCR continued to increase risk of death, with mortality nearing 45% in patients who had 4 or more viruses detected during their ICU admission. Conclusion Viral DNAemia was common and associated with mortality in pediatric patients with severe sepsis. DNAemia with 2 or more viruses increased mortality risk, even in previously healthy patients. EBV seropositivity was strongly associated with PICU mortality, independent of concurrent viral DNAemia. Disclosures Andrew H. Walton, MS, RevImmune: Grant/Research Support|Thermo Fisher: Spouse employed by Thermo Fisher.

430: VIRAL DNAEMIA IS ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH SEVERE SEPSIS

Introduction: Sepsis is a leading cause of pediatric mortality. Little attention has been paid to the contribution of latent and reactivated viral infection to critical illness in children with sepsis. We report a large multicenter study of viral DNAemia and herpesvirus seropositivity in pediatric patients with severe sepsis. Methods: We enrolled 401 pediatric patients from 9 Pediatric Intensive Care Units (PICUs). Patient samples were tested via qPCR for EBV, CMV, HSV, adenovirus, HHV6, BK and parvovirus B19 DNA. CMV, EBV, HSV and HHV6 IgG were also measured to classify patients as having no infection (IgG-negative without DNAemia), acute infection (IgG-negative with DNAemia), reactivated infection (IgG-positive with DNAemia), or latent infection without reactivation (IgG-positive without DNAemia). Results: 55% of enrolled patients were male, 39% previously healthy, and 27% immunocompromised. 56% had documented infection(s) on enrollment (63% bacterial, 50% viral, and 2% fungal). 10% died in the PICU. Viral DNAemia was detected in 61% of immunocompromised patients and 46% of non-immunocompromised patients. DNAemia with 2 or more viruses on study, detected in 21% of patients, was independently associated with increased mortality in both immunocompromised (OR 5.51 [1.6, 22.6] p=0.023) and non-immunocompromised patients (OR 3.93 [1.4, 11.5] p=0.015). Viral detection was due to reactivated infection in 91% of patients with EBV DNAemia, 63% with CMV, and 100% with HSV and HHV-6, making acute infection rare. Viral seropositivity (HSV 33%, CMV 42%, EBV 61%, HHV6 98%) and latent infection (HSV 30%, CMV 35%, EBV 45%, HHV6 75%) were both common. Adjusted mortality was higher in patients seropositive for EBV (OR 9.1 [2.78, 172.8], p=0.002) compared to those seronegative for EBV. For HHV-6, mortality was higher in patients with viral reactivation compared to latent infection (18% vs. 7%, p=0.024). Mortality in patients with no detected viral infection (IgG-negative without DNAemia) was low (≤ 5% for each virus). Conclusions: Viral DNAemia was common and associated with mortality in pediatric patients with severe sepsis. DNAemia with 2 or more viruses increased mortality, even in previously healthy patients. EBV seropositivity was strongly associated with PICU mortality, independent of concurrent viral DNAemia.

SERO-PREVALENCE OF EPSTEIN-BARR VIRUS IN IRAQI INFLAMMATORY BOWEL DISEASE.

The aim: Determine the frequency of anti-viral capsid antigen IgM, IgG and IgA in inflammatory bowel disease. Materials and methods: Case controlled study conducted during involved 60 Crohn's disease, 60 ulcerative colitis and 60 subjects as a control group with negative gastroin¬testinal symptoms. Diagnosis and disease classification were established according to Montreal disease classification of inflammatory bowel diseases. Measurement of serum anti-VCA IgM, IgG and IgA was done, using ELISA method. Results: The current results showed a higher frequency of EBV seropositivity among both Crohn's disease and ulcerative colitis 96.67% in comparison with controls 78.33. None statistical significance observed according to sex of patients. IgM were significantly associated with younger than 16 years 33.33%. IgA anti-VCA were significantly frequent within 17-40 years old comprising 100%. Patients with colonic and ileocolonic site of lesions were significantly have frequent anti-VCA IgA 96.43% and 96%. In ulcerative colitis IgM subtype of anti-VCA 35.71% frequent in extensive colitis. Anti-VCA IgG were statistically significant with moderate and severe ulcerative colitis cases 100%. Also, anti-VCA IgA associated with severity of ulcerative colitis 100% of mild cases, 96.43% of moderate cases and 100% of severe cases. Conclusion: EBV seropositivity were detected among IBD cases, however viral infection might be associated with distinct and severe cases that requires anti-viral therapy.

A systematic review of post-transplant lymphoproliferative disorder after liver transplant.

e19045 Background: Post-transplant lymphoproliferative disorder (PTLD) is a complication after liver transplantation. This study aims to explore the association of PTLD with the immunosuppression, types of PTLD, clinical presentation, and outcomes. Methods: Following the PRISMA guideline, we searched the literature on PubMed, Cochrane, Embase, and clinicaltrials.gov. 1741 articles were screened and 22 studies were included. Results: Data includes 22,235 total patients who underwent a liver transplant, and 449 (2.0%) patients who developed PTLD were studied. Of the 394 patients where gender was reported, 226 were male and 168 were female. Post-transplant EBV status was positive for 63/115 (56%). 11 studies showed that the median time from transplant to the development of PTLD was 33.4 months. Among the histological types of PTLD, the monomorphic B-cell was the most common type with 127/235 (54%) cases, followed by early lesions 25/235, polymorphic 24/235, Hodgkin lymphoma 8/235, and monomorphic T-cell type 7/235. Treatment of PTLD involved reduction or cessation of the immunosuppressive drugs along with chemotherapy surgery and radiotherapy. Mortality data from 13 studies showed 68/259 (31.3%) patients died either due to PTLD or its complication. Conclusions: PTLD is rare but associated with high mortality after liver transplantation. EBV seropositivity is associated with PTLD in the majority of cases. Monomorphic PTLD is the most common type of PTLD after liver transplantation with DLBCL being the most common subtype. Abdominal symptoms and fever are among the most common symptoms. PTLD after Liver transplant a review of studies. [Table: see text]

A systematic review of post-transplant lymphoproliferative disorder after lung transplant.

e19046 Background: Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid organ transplantation. This study aims to explore the association of PTLD diagnosed after lung transplant with infectious agents and immunosuppression regimen, explore types of PTLD, and their outcome. Methods: Following the PRISMA guideline, we searched the literature on PubMed, Cochrane, Embase, and clinicaltrials.gov. 1741 articles were screened and included five studies. Results: We analyzed data from five studies, n=13,643 transplant recipients with n=287 (2.10%) developed PTLD. Four studies showed that 32/63 (51%) PTLD patients were male and 31 (49%) were female. Three studies reported 53/55 (96.4%) patients were EBV positive at PTLD diagnosis. Courtwright. et al, reported that 217/224 (97%) PTLD was associated with either EBV positive donor or recipient. Four studies showed that the monomorphic B cell type 48/63 (76%) was the most common histological type of PTLD diagnosed with DLBCL the most common subtype 31/48 (64.6%). Data from 3 studies showed that the onset of PTLD following lung transplant varies with a median duration of 18.3 months (45 days to 20.2 years). Three studies showed that 26/55 (47.3%) patients had early-onset (≤ 1 yr of Tx) and 29/55 (52.7%) patients had late-onset PTLD (> 1 yr of Tx). Management of PTLD included a reduction in immunosuppression including corticosteroids, CNI, purine synthesis inhibitors, Rituximab, and chemotherapeutic agents. Three studies showed a mortality rate of 30/45 (66.7%) and 13/30 (43.3%) deaths were PTLD related. Conclusions: Our review concludes that PTLD is a serious complication, only 2% of lung transplant recipients developed PTLD. EBV seropositivity is the most factor associated with PTLD diagnosis. Monomorphic PTLD was reported as the most common type in the adult population and no association between gender and PTLD was found. The analysis shows that there is a slightly lower incidence of early (≤ 1 yr of Tx) than late-onset (> 1 yr of Tx) PTLD. Table 1 PTLD after a Lung transplant in adults - a review. [Table: see text]

Assessment of Systemic Lupus Erythematosus in Term of Serum Anti-nucleosome and Interleukin 12 Markers in Relation to Epstein–Barr virus and Cytomegalovirus

Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease, more dominant in female, associated with high risk of life threating complication and increase morbidity and mortality. the exact cause of SLE is not yet known with many suggestions about a possible role of viral infection in the development of the disease. Epstein –Barr virus is the most commonly studied virus in an attempt to prove its presumed association with development of SLE.The objectives of this study are the measurement of the effect of CMV and EBV seropositivity in the auto immune status and severity of disease SLE measured by estimating the level of immunological markers anti-nucleosome and IL-12 with viral marker. Materials and Method: Forty newly diagnosed female with SLE were randomly selected from patient attended rheumatology clinic at medical city in Baghdad during the period between December 2018 to May In addition, with 40 apparently healthy females, as, a control groups. Both group were investigated for IL12, anti-nucleosome, EA, VCA, EBNA and CMV by ELISA and the results were statistically evaluated. Results: The studied viral markers in the current study which included EBV markers EA, VCA, EBNA, have shown significantly higher level compared to the control group. Similarly, anti-nucleosome and IL12 have shown significantly higher level compared to the control group. Conclusions: The possible defect in controlling viral infection and increased number of latent infected cell in SLE may enhance production of auto-antibodies

Epidemiology of Epstein-Barr virus infection and infectious mononucleosis in the United Kingdom

BackgroundEpstein-Barr Virus (EBV) is a ubiquitous gamma-herpesvirus with which ~ 95% of the healthy population is infected. EBV infection has been implicated in a range of haematological malignancies and autoimmune diseases. Delayed primary EBV infection increases the risk of subsequent complications. Contemporaneous seroepidemiological data is needed to establish best approaches for successful vaccination strategies in the future.MethodsWe conducted a sero-epidemiological survey using serum samples from 2325 individuals between 0 and 25 years old to assess prevalence of detectable anti-EBV antibodies. Second, we conducted a retrospective review of Hospital Episode Statistics to examine changes in Infectious Mononucleosis (IM) incidence over time. We then conducted a large case-control study of 6306 prevalent IM cases and 1,009,971 unmatched controls extracted from an East London GP database to determine exposures associated with IM.Results1982/2325 individuals (85.3%) were EBV seropositive. EBV seropositivity increased more rapidly in females than males during adolescence (age 10–15). Between 2002 and 2013, the incidence of IM (derived from hospital admissions data) increased. Exposures associated with an increased risk of IM were lower BMI, White ethnicity, and not smoking.ConclusionsWe report that overall EBV seroprevalence in the UK appears to have increased, and that a sharp increase in EBV seropositivity is seen in adolescent females, but not males. The incidence of IM requiring hospitalisation is increasing. Exposures associated with prevalent IM in a diverse population include white ethnicity, lower BMI, and never-smoking, and these exposures interact with each other. Lastly, we provide pilot evidence suggesting that antibody responses to vaccine and commonly encountered pathogens do not appear to be diminished among EBV-seronegative individuals. Our findings could help to inform vaccine study designs in efforts to prevent IM and late complications of EBV infection, such as Multiple Sclerosis.

EBV-MEDIATED POSTTRANSPLANT LYMPHOPROLIFERATIVE DISORDER PRESENTING AS A PLEURAL EFFUSION AND ACUTE CELLULAR REJECTION: A CASE REPORT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a rare complication following adult lung transplantation, but carries a three-fold increase in the risk of death compared to non-sufferers (1). Described manifestations of PTLD include lung nodules & infiltrates, thoracic adenopathy, GI involvement and CNS mass lesions (2). CASE PRESENTATION: A 59 year-old male with a history of cystic fibrosis underwent bilateral lung transplantation for progressive hypoxic respiratory failure needing VV-ECMO; he suffered no significant complications until he developed fatigue and a 600mL drop in FEV1 two months post-transplant. A right lung opacity was found on CXR; he received antibiotics for pneumonia, but his symptoms persisted. Chest CT demonstrated mediastinal and hilar lymphadenopathy, and a large right sided effusion (Image 1). Flow cytometry on pleural fluid obtained from thoracentesis showed kappa-light-chain restricted plasmacytic cells, consistent with PTLD. An EBV PCR returned positive (584cpy/mL). He underwent bronchoscopy with transbronchial lung biopsy, endobronchial ultrasound-guided transbronchial lymph node sampling and tunneled pleural catheter placement for recurrent effusion. Pleural fluid again showed plasmacytoid cells. The transbronchial biopsy showed perivascular mononuclear cell infiltrates with endothelialitis and septal extension, concerning for grade A3 rejection. His EBV viremia worsened (2660cpy/mL). After a multidisciplinary discussion, it was decided his pathologic findings were due to PTLD; he was treated with reduction of immunosuppression and four weeks of rituximab. After the first dose, his EBV load dropped by almost half, and his FEV1 recovered. After four doses, his serum EBV was undetectable, and repeat CT showed near-resolution of the adenopathy (Image 2). DISCUSSION: Cystic fibrosis patients are at higher risk for PTLD, likely because they are younger at transplant and therefore tend to be EBV seronegative when transplanted (3). Adult EBV seropositivity is pervasive, and lung tissue is lymphoid-rich (2); transplanted lungs may carry a high load of infected B-cells to the recipient, who then receive therapies to suppress host immunity (including cytotoxic T-cells that check the infected lytic-phase B-cells which perpetuate infection) (2). While treatments differ by center, the anti-CD20 monoclonal antibody rituximab is often used to deplete B-cells, in tandem with reducing immunosuppression (2). Remission rates range from 52-66%, with better outcomes for early-onset PTLD and EBV positive patients (2). CONCLUSIONS: Our patient was unique in manifesting with a pleural effusion as a primary site of his PTLD, though he also had lymphadenopathy that regressed with therapy. While older and a cystic fibrosis patient, he had positive prognostic factors (early presentation, EBV-positivity), and ultimately had a good outcome from rituximab and reduced immunosuppresion. Reference #1: Zaffiri L, Neely M, Cherikh W, et al. Incidence and Outcomes of Post-lymphoproliferative Disorder in Lung Transplant Recipients. Analysis of the ISHLT Registry. J Heart Lung Transplant 2018; 37(4): S450. Reference #2: Green M and Michaels MG. Epstein-Barr Virus Infection and Posttransplant Lymphoproliferative Disorder. Am J Transplant 2013; 13: 41-45. Reference #3: Lowery EM, Adams W, Grim SA, et al. Increased risk of PTLD in lung transplant recipients with cystic fibrosis. J Cyst Fibrosis 2017; 16: 727-734. DISCLOSURES: No relevant relationships by Luis Angel, source=Web Response No relevant relationships by Melissa Lesko, source=Web Response No relevant relationships by Sunil Nair, source=Web Response

Smoking can increase nasopharyngeal carcinoma risk by repeatedly reactivating Epstein-Barr Virus: An analysis of a prospective study in southern China.

BackgroundThe association between smoking and nasopharyngeal carcinoma (NPC) is still uncertain. The aim of this study was to validate smoking effect on NPC and explore if smoking can induce NPC by persistently reactivating EBV in long‐term based on a prospective cohort design.MethodsA NPC screening cohort with 10 181 eligible residents in Sihui city, southern China was conducted from 2008 to 2015. The smoking habit was investigated through the trained interviewers and EBV antibodies (VCA‐IgA, EBNA1‐IgA) as screening markers were tested periodically. New NPC cases were identified through local cancer registry. Cox's regression model was used to estimate the adjusted hazard ratios (aHRs) of smoking on NPC incidence. In the non‐NPC participants, the associations between smoking and EBV seropositivity in different periods were assessed by logistic regression and generalized estimating equations (GEE).ResultsWith a median of 7.54 years, 71 NPCs were diagnosed ≥1 year after recruitment. Compared with never smokers, the aHRs of developing NPC among ever smokers were 3.00 (95%CI: 1.46‐6.16). Stratified by sex, the HRs of ever smoking were 2.59 (95%CI: 1.07‐6.23) for male and 3.75 (95%CI: 1.25‐11.20) for female, respectively. Among the non‐NPC individuals, ever smoking was not only associated with EBV seropositivity at baseline, but also in the 3‐5 years of follow up, with adjusted odds ratios (aORs) of 1.68 (95%CI: 1.29‐2.18) for VCA‐IgA and 1.92 (95%CI: 1.42‐2.59) for EBNA1‐IgA. Among the smokers who were tested EBV antibodies at least twice, the similar results were obtained using GEE.ConclusionSmoking could significantly increase the long‐term risk of NPC in southern China, partly by persistently reactivating EBV.

A Case of Infectious Mononucleosis with Concurrent EBV and CMV IGM Seropositivity

A Case of Infectious Mononucleosis with Concurrent EBV and CMV IGM Seropositivity

EBV Seropositivity in Sjögren's Syndrome Secondary to Rheumatoid Arthritis

EBV Seropositivity in Sjögren's Syndrome Secondary to Rheumatoid Arthritis

Risk factors for multiple sclerosis and associations with anti-EBV antibody titers

Multiple sclerosis (MS) is an inflammatory demyelination of the central nervous system. We investigated the prevalence of EBV seropositivity and other known risk factors for MS (age, smoking, low vitamin D) and their effect on anti-EBV antibody titers. We retrospectively studied 249 MS patients receiving care at the American University of Beirut Medical Center and 230 controls, during 2010–2014. EBV seropositivity was higher in MS patients compared to controls for both anti-VCA (99.5%; 97.2%) and anti-EBNA-1 (96.3%; 89.4%), and the titers were significantly higher in MS patients. MS patients had a significantly lower vitamin D level (15.5±8.3ng/ml) compared to controls (20.4±11.3ng/ml). The proportion of heavy smokers and overweight individuals was significantly higher in MS patients. Lebanese MS patients have risk factors similar to those in western countries. Older age and female gender were associated with a higher anti-VCA titer and male gender with a higher anti-EBNA-1.

Cytomegalovirus-Seropositive Children Show Inhibition of In Vitro EBV Infection That Is Associated with CD8+CD57+ T Cell Enrichment and IFN-γ

EBV, a human herpesvirus, is commonly acquired during childhood and persists latently in B cells. EBV seropositivity has been connected to immunomodulatory effects such as altered T and NK cell functional responses as well as protection against early IgE sensitization; however, owing to the asymptomatic presentation during childhood little is known regarding the infection process in children of different ages. In this study, we used mononuclear cells from cord blood and from 2- and 5-y-old EBV-naive children for in vitro EBV infection. We show that the degree of EBV-induced B cell activation and expansion differs between age groups and in particular in relationship to IFN-γ production capacity. EBV infection induced redistribution between B cell subsets with enrichment of IgD(+)CD27(+) cells (commonly referred to as non-switched memory) in infected cord blood cell cultures, and of IgD(-)CD27(+) cells (switched memory) in cell cultures from older children. We also related results to serostatus to CMV, a persistent herpesvirus that can affect differentiation status of T and NK cells. As compared with CMV(-) children, the EBV-induced enrichment of IgD(-)CD27(+) B cells was significantly reduced in infected cell cultures from CMV(+) children. This effect was associated with high levels of IFN-γ and frequencies of highly mature CD8(+)CD57(+) T cells in CMV(+) children. Our results demonstrate that both a child's age and serostatus to CMV will have an impact on EBV-induced B cell activation and expansion, and they point to the ability of viruses with immunomodulatory functions, such as CMV, to affect immune responses within the host system.

Clinical significance of peripheral blood Epstein–Barr viral load monitoring using polymerase chain reaction in renal transplant recipients

PTLD is a complication of EBV infection. We examined the efficacy of EBV-PCR monitoring to detect early replication in an attempt to prevent EBV-associated PTLD. Blood EBV levels in 156 renal transplant recipients (58 children) from three institutions over nine yr were retrospectively analyzed. Patients who were asymptomatic and at high risk for PTLD were monitored for EBV infection by PCR or serology followed by PCR at the time of EBV seropositivity. More children than adults had positive EBV-PCR (12/58 vs. 2/98, p < 0.001). Adults remained asymptomatic and viremia resolved post-therapy. 3/12 EBV-PCR positive children developed PTLD (3/12 children vs. 0/2 adults, p = NS). Two out of three with PTLD were initially monitored by serology, and later by PCR. PTLD resolved post-therapy in all three patients. The remaining 9/12 EBV-PCR positive children stayed asymptomatic. None of the children and adults with negative EBV-PCR developed PTLD. EBV-PCR monitoring in high-risk renal transplant recipients, especially in children, may allow early diagnosis and intervention, and therefore may help in preventing EBV-associated PTLD.

Impact of CMV and EBV seropositivity on CD8 T lymphocytes in an old population from West-Sicily

Herpes viruses (particularly CMV and to some extent EBV) might play a role in accelerating the deterioration of immune functions with age. Indeed, it has been demonstrated that chronic infection with CMV causes an expansion of specific CD8 T lymphocytes and that this is related to a shrinkage of the T cell repertoire in very elderly people, predicting mortality. We have analysed CD8 T cells in young and old healthy Sicilians who were both CMV- and EBV-seropositive. Our data confirm expansions of T cells specific for the HLA-A2-restricted pp65 (495–503) CMV epitope up to nearly 14% of total peripheral CD8 cells in certain elderly individuals (range 0–14%). However, the mean percentage of CMV-specific cells in the elderly was not greater than the young (range 0.2–3%). The CMV-specific CD8 cells in the elderly were predominantly CD45RA+, but in the young they were mostly CD45RO+. Our findings are somewhat different from published reports from Northern European populations, both in terms of mean numbers and surface phenotypes. These findings may reflect disparate hygienic and nutritional conditions 70–90 yr ago, which were very different in Northern and Southern Europe at that time, as well as a different genetic background.

Case–control study of risk factors for the development of post‐transplant lymphoproliferative disease in a pediatric heart transplant cohort*

PTLD is an important complication following heart transplantation. To better define the risk factors of PTLD in children, we performed a case-control study. All pediatric cardiac transplant recipients who developed their first episode of PTLD were matched by age (+/-1 yr) and time since transplant (+/-1 yr) with those who did not. PTLD occurred in nine of 95 cardiac transplant recipients (9%), 0.3-7.8 yr following cardiac transplantation (median = 2.5 yr). Patients were 0.1-16.4 yr (median = 3.7) at transplantation. Biopsies revealed polymorphic B cell hyperplasia (three), polymorphic B cell lymphoma (one), monomorphic diffuse large cell B cell lymphoma (three) and monomorphic Burkitt's-like lymphoma (two). Patients who developed PTLD were at no greater risk of death (p = 0.31). Recipient EBV seronegativity at time of transplant (p = 0.08), EBV seroconversion (p = 0.013) and recipient CMV seronegativity (p = 0.015) were associated with the development of PTLD by conditional logistic regression; sex, race, donor age, recipient diagnosis, donor CMV seropositivity, recipient treatment for CMV infection, EBV seropositivity at the time of PTLD diagnosis, and number of rejection episodes, treated rejection episodes, and lympholytics used were not. There was no significant association between PTLD and death in our recipients. EBV seroconversion and recipient CMV seronegativity were associated with the development of PTLD.

Prediagnostic Circulating Antibodies to JC and BK Human Polyomaviruses and Risk of Non-Hodgkin Lymphoma

Viral infections have been associated with increased risk of non-Hodgkin's lymphoma (NHL). We conducted a nested case-control study to investigate the association between prediagnostic serum antibodies to the human polyomaviruses, JC (JCV) and BK (BKV), and subsequent risk of NHL. Two research serum banks were established in Washington County, Maryland, in 1974 and 1989, with the collection of blood samples from >45,000 volunteers. Incident NHL cases diagnosed through 2002 (n = 170) were identified among participants by linkage to population-based cancer registries. Two controls were matched to each case (n = 340) on age, sex, and blood draw date. Prediagnostic IgG antibodies to JCV and BKV were measured using virus-like particle ELISA. Associations between JCV and BKV antibody seropositivity and NHL were estimated using conditional logistic regression. Overall, neither antibodies to JCV [odds ratio (OR), 0.83; 95% confidence interval (95% CI), 0.56-1.23] nor BKV (OR, 0.98; 95% CI, 0.64-1.48) were associated with an increased risk of NHL. Results were similar after stratification by NHL subtype or induction period and adjustment for EBV seropositivity. Among those who donated blood in both 1974 and 1989, an increase in JCV antibody levels over time was associated with a 4-fold increased risk of NHL compared with a steep decline in antibody levels (OR, 4.59; 95% CI, 1.30-16.25; P(trend) = 0.02). Whereas JCV seropositivity was not associated with NHL overall, the finding of an increased risk of NHL associated with increasing antibody levels among those who were seropositive at baseline warrants further research into factors influencing reactivation of JCV infection.

Epstein-Barr virus-related disorders in children undergoing renal transplantation with tacrolimus-based immunosuppression.

In children undergoing renal transplantation, Epstein-Barr virus- (EBV) related disorders, including posttransplant lymphoproliferative disorder, constitute a major complication associated with tacrolimus-based immunosuppression. In this study, we reviewed the EBV complications in 81 children, all of whom had EBV serological studies before renal transplantation. We also highlight the data in a subgroup of 30 children transplanted more recently who were monitored sequentially for EBV symptoms and signs and with immunological studies, and in whom the donor EBV serology was also determined. During a mean follow-up time of 3.9+/-2.3 years, 19 children developed symptomatic Epstein-Barr virus (EBV*) infection. This consisted of the clinical syndrome of infectious mononucleosis in 7 children; in addition, 10 children developed posttransplant lymphoproliferative disorder (PTLD), which was histologically confirmed in 8, and 2 others developed malignant lymphoma. Recipient seronegativity (EBV-) and donor EBV seropositivity (EBV+) predicted a high probability for seroconversion (P=0.0072) and for developing PTLD or malignancy (P<0.01). In the subgroup of 30 children studied prospectively, seroconversion occurred in 15 of 19 seronegative recipients of EBV seropositive grafts at 6.6+/-2.6 months (mean+/-SD) after transplantation. Seven children developed symptomatic EBV infection (including three with PTLD) in association with seroconversion and a rise in EBV viral load in the peripheral blood, demonstrated by an EBV-specific polymerase chain reaction (EBV-PCR). Of 15 seroconverters, 7 who developed symptomatic infection had received EBV+ grafts; 8 others with EBV+ grafts seroconverted but did not become symptomatic. These two subgroups did not differ in age, rejection rate, antiviral prophylaxis, or level of immunosuppression. In the overall group of 81 children, only the two with malignant lymphoma who were managed with chemotherapy had substantial morbidity. The 10 individuals with PTLD received a regimen combining i.v. ganciclovir and CytoGam, and stopping or reducing the tacrolimus. Four children with associated marked tonsilar growth underwent tonsillectomy. All 19 individuals with EBV disorders resolved their symptoms and signs, and all have maintained good allograft function during a follow-up time of 3.0+/-2.5 years (mean+/-SD) after the development of symptomatic EBV infection, PTLD, or malignancy. We conclude that seronegative recipients of EBV+ grafts are at high risk for developing EBV-related disorders after renal transplantation under tacrolimus-based immunosuppression, although the ultimate clinical outcomes have been remarkably good. These data form the basis for formulating strategies for early identification of children at risk for EBV complications, and for instituting preventive and treatment strategies that permit these children to realize the substantial benefits offered by tacrolimus-based immunosuppression.

Correlation between Epstein Barr virus antibodies, serum IgE and atopic disease.

It is currently accepted that viral infections may influence the development of atopy. In the present study we evaluated serum IgE levels as well as the prevalence of symptoms indicative of atopic disease and EBV antibodies in 353 children aged from 1 month to 19 years. Antibodies against EBV were detected by immunofluorescence. IgE levels in serum were measured by enzyme immunoassay. Dividing the study population according to EBV seropositivity and age, we noted that the prevalence of high IgE levels (> 2 s.d.) was, in total, more frequent in the EBV negative (32.9%) than in the positive subjects (27.6%). Interestingly, this higher prevalence was found only in the groups aged under six, especially in the 7 to 29 month group, where it was statistically significant (p=0.037), whereas in the 6-19 year group the situation was reversed. Furthermore, selecting only the atopic children younger than 3 years of age with high IgE levels and clinical symptoms of atopy (wheezing and/or dermatitis) it was possible to demonstrate lower EBV seropositivity compared with the normal IgE controls for each group, even though these differences were not statistically significant. In conclusion, the results of our study suggest that, in our selected population, EBV infection in the first years of life is associated with a lower prevalence of high IgE levels.

A putative new retrovirus associated with multiple sclerosis and the possible involvement of Epstein-Barr virus in this disease.

Since tropical spastic paraparesis in 1985 was found to be associated with HTLV-I infection, it has been suggested that a retrovirus might be involved in multiple sclerosis (MS). Our group has studied long-term cultures of cerebrospinal fluid cells and peripheral blood mononuclear cells from MS patients and controls with the purpose of elucidating the possible involvement of a retrovirus in MS. For an extended period electron microscopical analysis (EM) of T-cell lines, derived from MS patients and controls and cultured for 4 weeks was performed. In two cultures obtained 8 months apart from a patient with progressive MS, retrovirus-like particles were observed in 1-2% of the cells examined. Recently a B-lymphoblastoid cell line (LCL) producing retrovirus-like particles and EBV was established from a 30-year-old male patient with a chronic progressive myelopathy, clinically resembling multiple sclerosis. Similar cell lines have now been established from two MS patients. The retrovirus-like particles produced by the LCL have been purified by gradient ultracentrifugation. In the purified material reverse transcriptase assays are clearly positive in the gradients where EM shows retrovirus-like particles. Antigen characterization, nucleic acid sequence analysis and antibody studies are now being performed. The retrovirus found is definitively different from other known human retroviruses. It has previously been found that 100% of patients with MS have antibodies against EBV, in contrast to controls where only 86-95% have antibodies against this virus. Previous epidemiological studies have pointed toward a post-pubertal primary EBV infection as an important event in the induction of MS disease. These studies have now been substantiated by our group. Though it is still unknown whether EBV infection is a prerequisite for development of MS or whether the 100% EBV seropositivity is a consequence of the MS disease, we have put forward the hypothesis that the etiological agent for development of MS and MS-like diseases is a new hitherto uncharacterized retrovirus, whereas development of neurologic disease is related to or even dependent on a delayed infection with a virus from the herpes group, most likely EBV. This dual infection hypothesis has been analyzed and was found to be in accordance with the most consistent epidemiological characteristics of MS. We have previously, also from epidemiological data, negated retroviruses, behaving as the known human retroviruses, as an independent cause of MS.